Page 151 - MEDIFAB_Digital_CatalogueCA

Client Details Form A

(Please attach to Generic Order Form)

Therapis t Details Client Details
Name: Name:
Organisation: DOB: / / Male Female
PO Box: Carer/Parent:
Suburb: Address:
City:
Country:
Ph: Ph:
Email: Email:
Mobile: Please exclude from Medifab client database

CLIENT MEASUREMENTS Dated / /
In Sitting: I
F
A] Lower leg (L) mm
H
(R) mm D
E
B] Upper Leg Length (L) mm C G J
(R) mm
B
C] Lower Trunk Depth mm
A
D] Shoulder Height mm
E] Axilla Height mm
F] Chest Depth mm
G] Hip Width mm
O
H] Chest Width mm
I] Shoulder Width mm P
J] Sacral/Lumbar Height mm
Q
K] Seat to Back Angle mm
N M L
In Standing: (can be measured lying down)
L] Total Height mm
M] Axilla Height mm
N] Inner Leg Length mm
O] Chest Width mm
P] Chest Circumference mm s
Q] Hip Width mm
S
T rder Form
WHEELCHAIR MEASUREMENTS (If applicable)
R] Frame Width mm R
S] Seat Rail Length mm
O
T] Backrest Cane Height mm

Form A